Provider Demographics
NPI:1154670826
Name:DUBAN, CARLA RUTH (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RUTH
Last Name:DUBAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63188-0551
Mailing Address - Country:US
Mailing Address - Phone:314-814-8531
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:4414 N FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-1812
Practice Address - Country:US
Practice Address - Phone:314-814-8531
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2011012286208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011012286OtherLICENSE